The speaker of this dramatic monologue in prose
is an archangel. He attempts to tell his
listeners—mortals, presumably—of the beauty to be treasured in the
extraordinary ordinary of the everyday world.
The Archangel speaks in nothing less than glorious diction, baroque
syntax, and enchanting rhythm: he labors, rhetorically, to communicate in a
language congruent with the complex, extravagant beauty of the world he
describes. He pleads with his audience
to listen to him and share in the profound aesthetic experience so readily
available—but he pleads to no avail: his audience will not listen. In response to his audience's attempted
departure, the Archangel implores, “Wait.
Listen. I will begin again.”

The narrator of this story is a lifeguard who contemplates
his identity and life-roles as he lounges in his lifeguard chair, elevated
above the crowd of beachgoers. In the
winter months, he is a student of divinity; in the summer months, he ascends
the throne marked with a red cross in the hopes of guarding the lives of those
at play before him. While he remains
vigilant for calls of help, those calls never come, and the lifeguard confronts
the troubling insight of the limited contributions he’s devoting his life to
make.

Frank
Drum, 13, and his younger brother Jake are catapulted into adulthood the summer
of 1961 in their small Minnesota town as they become involved in investigation
of a series of violent deaths. Their
father, a Methodist minister, and their mother, a singer and musician, can’t
protect them from knowing more than children perhaps should know about suicide,
mental illness, and unprovoked violence.
The story is Frank’s retrospective, 40 years later, on that summer and
its lasting impact on their family, including what he and his brother learned
about the complicated ways people are driven to violence and the equally
complicated range of ways people respond to violence and loss—grief, anger, depression,
and sometimes slow and discerning forgiveness.

In 1942, Beth Pierce was completing her
internship in the new discipline of occupational therapy in a Baltimore hospital
where she meets Jim, a conscientious objector who is training to become a medic.
They share a love of poetry and the arts. He goes off to war and serves in the foxholes
and trenches of the dreadful conditions at the front. She stays in North
America serving in rehabilitation with the war wounded – young men damaged
physically and mentally from the great trauma. Until 1945, they exchange a
remarkable series of letters that describe the war, their parallel work with
the war wounded, their hopes for the future, and gratitude for each other’s
thoughts. The letters always close with “Please write.”

Born in 1894, Grania becomes deaf following scarlet fever at the age of two. Her mother never quite recovers from misplaced guilt over this outcome and is withdrawn. But Grania is well loved by the whole family, who run a hotel in a small town. Her older sister and their Irish-born grandmother see the child's intelligence and find ways to communicate with her by signs and words; they urge the parents to send her to a special school.By age nine, Grania is sent to the famous School for the Deaf in Belleville Ontario, founded by Alexander Graham Bell. Although the school is only a short distance from her home on the north shore of Lake Ontario, the child is not allowed to return for nine long months. At first she is overwhelmed with homesickness, but soon she finds kindred spirits among the other students and teachers and adapts to the life of the institution.

By 1915, her studies complete, Grania works at the school. There, she meets her future husband, Jim, a hearing man who is assistant to the town doctor. They marry, but only two weeks later, Jim leaves to serve as a stretcher bearer in the war in Europe. Fear and death haunt the people at home and abroad for years. Jim writes what little he is allowed of the horror and danger around him, always promising to return. Grania waits and writes too, slowly growing hopeless and angry, as devastating telegrams arrive one after the other.Her sister copes with the return of a grievously disfigured husband, wounded more in mind than in body. In late 1918, Grania falls ill in the influenza epidemic and is delirious for weeks. When she recovers, frail and bald, she learns of the loss of her beloved grandmother who died of the fever caught by nursing her. At the same moment she hears of the war's end and begins to believe again in hope.

The
aim of these reflections on uncertainty in medicine is not to discredit
evidence-based medicine or to incite suspicion of the careful and caring
processes by which most clinicians arrive at the advice they give. Rather it is to change conversations among
practitioners and between them and their patients in such a way as to raise
everyone’s tolerance for the inevitable ambiguities and uncertainties we live
with. If the public were more aware of
the basic rules of mathematical probabilities, how statisticians understand the
term “significance,” and of how much changes when one new variable is taken
into account—when a new medication with multiple possible side-effects is added
to the mix, for instance—they might, Hatch argues, be less inclined to insist on
specific predictions. He goes on to
suggest that there is something to be gained from the challenge of living
without the solid ground of assurances.
When we recognize the need to make decisions with incomplete information
(a condition that seems, after all, to be our common lot) we may refocus on the
moment we’re in and see its peculiar possibilities. Changing the conversation
requires a critical look at medical education which, Hatch observes, “measures
a certain type of knowledge essential to medical practice, but it consequently
engenders a conception of medicine best described as overly certain . . . .”

This is the third book in a series on the history of medicine and medical education by Kenneth M. Ludmerer, a practicing physician and historian of medicine at Washington University of St. Louis. The first, Learning to Heal: The Development of American Medical Education, published in 1985, dealt with the history of medical schools and medical education in the US from their origins in the 19th century to the late 20th century. In 1999 he published Time to Heal: Medical Education from 1900 to the Era of Managed Care. This book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, published in 2015, is a sweeping history of graduate medical education in the United States from its inception to the current day.

In 13 chapters and 431 pages (334 pages of text, 97 of reference and index), Ludmerer traces the residency from early apprenticeship days to its metamorphosis (at Johns Hopkins, of which he is a justly proud medical school alumnus) into the embryonic form of what we now call an internship and residency. Giants like “The Four Doctors” (to use the title of John Singer Sargent’s famous portrait of William S. Halsted, William Osler, Howard A. Kelly and William H. Welch - but known simply as “The Big Four” at Hopkins) were the godfathers of the American postgraduate medical model which emphasized clinical science, teaching, patient care and research. The rise of acute care teaching hospitals as the venue of postgraduate medical education, and not the medical school or university, is an interesting story and one which Ludmerer tells in great detail over a number of chapters. It is one replete with predictable turf wars, professional turmoil and politics, and societal change in all aspects of the 20th century. This last phenomenon receives its due attention in every chapter but is dissected in meticulous detail in the final chapters dealing with the Libby Zion case, duty hours and the increasing role of the Accreditation Council for Graduate Medical Education (ACGME) in postgraduate medical education.

Beginning in the 1930’s, American medicine grew increasingly specialized and, in the ensuing decades, subspecialized, much to the consternation of pre-WW II general practitioners who, suddenly and for the first time, found themselves in the minority, in numbers and in influence, of their own profession. Concomitant with the phenomenon of specialization was the imprimatur by academic medicine of the structured, sanctioned residency as the sole route to specialty practice with, of course, the birth of associated accrediting agencies. Along with the move, physically, academically and politically, of postgraduate medical education to acute care teaching hospitals, the control of this education moved from medical schools to the profession at large.

Ludmerer deftly describes the “era of abundance”, the salad days of postgraduate medical education in the 1950’s and 1960’s when giants still made rounds on the floors of postgraduate medical venues; funds were plentiful; outside criticism was an as yet unborn bête noir; and social, economic and governmental curbs were only a tiny distant cloud in an otherwise blue sky. Ludmerer is correct in attributing much of medicine’s professional and social hegemony as well as its transient immunity to criticism in this era to the following evident successes of medicine: antibiotics; initial inroads into antineoplastic therapies; startling technological innovations in imaging; a burgeoning spate of life-saving vaccines; and spectacular advances in surgery, especially pediatric, cardiothoracic and transplant. Fatal diseases of the 1930’s and 1940’s were now often cured in days and of historical interest only.

Like all salad days, those of medicine eventually succumbed to new historical forces: foreign medical graduates in the workplace; the ever-growing financial burden of the residency; and economic pressures like Medicare and its associated regulation. There were other factors, too: professional and societal expectations of standardization and quality care; the explosion in subspecialties; the horrid wastefulness of unnecessary diagnostic tests and therapies borne of an earlier undisciplined abundance; the supercession of the intimate primary physician-patient relationship by the fragmented care of specialists and the rising supremacy of technology over personalized histories and careful physical examinations (why percuss the abdomen when you can get a CAT scan?). Dissatisfaction amongst residents is a dominant theme Ludmerer rightly raises early and often: the conflict and tension between education and service, between reasonable work and “scut”, between being a student and a worker (at times, quite a lowly one).

”High throughput” - the much more rapid turnaround time between admission to an hospital and discharge - has radically changed forever the entire nature of postgraduate medical education, and not for the better in the eyes of the author and of this reviewer, who were fellow residents a lifetime ago at Washington University in St. Louis. This decreased length of stay, a result of the remarkable improvements in diagnosis and therapy mentioned above, meant that the working life of providers (attending physicians, residents, physician assistants and nurses) was in high gear from admission to discharge, thereby increasing tension, likelihood for error and, exponentially, the workload for the resident while simultaneously and irrevocably damaging the possibility of a meaningful, careful provider-patient relationship (like a friendship, of which it is a subspecies, such relationships can not be rushed) and decreasing opportunities for learning. Medicare; changing patient populations; societal and professional disgruntlement; the Libby Zion mess and the ensuing cascade of regulations from all sides, but most especially the ACGME - all receive careful and systematic treatment in the final chapters of this monograph.

Ludmerer ends with a chapter listing what he sees as opportunities for achieving (or re-achieving) excellence. Indeed, he has made it the book’s subtitle. They are the following: a plea for the ACGME to revise its 2011 duty-hour regulations; an equally earnest hope that interns and residents will soon realize a more manageable patient load; a related wish for academic medicine to decrease the unfortunate occurrence of economic exploitation of house officers; a suggestion that this annotator shares, i.e., that the process of supervision, improved (but inadequately) with recent ACGME requirements, be further strengthened; and a hope that medical schools will restore teaching to the central place in the institutional value system it used to enjoy. Ludmerer issues a call for the more vigorous promotion of “an agenda of safety and quality in patient care” (page 312) and suggests that the education of residents be expanded to include venues outside in-patient sites. Elsewhere in the book, he also expresses the expectation that the inclusion into clinical teaching of private patients alongside “ward” patients, more feasible with recent improvements in the re-imbursement of medical care, be routine and maximized to the enjoyment and benefit of all concerned.

Samuel Shem's (Stephen Bergman) The House of God, first published in 1978, has sold over two million copies in over 50 countries (see annotation). Its 30th anniversary was marked by publication of Return to The House of God: Medical Resident Education 1978-2008, a collection of essays offering historical perspectives of residency education, philosophical perspectives, literary criticism, and women's perspectives, among others. Contributors include such well-known scholars as Kenneth Ludmerer, Howard Brody, and Anne Hudson Jones, as well as physician-writers Perri Klass, Abigal Zuger, Susan Onthank Mates, and Jack Coulehan. The closing section, "Comments from the House of Shem," includes an essay by psychologist and scholar Janet Surrey (Bergman's wife) and one by "both" Samuel Shem and Stephen Bergman.

This memoir of a life in medicine takes the writer from
St. Louis to a Navajo reservation to Central America to the east coast and from
urban hospitals to ill-equipped rural clinics. It offers a wide range of
reflections on encounters with patients that widen and deepen his sense of
calling and understanding of what it means to do healing work. He learns to listen to tribal elders, to
what children communicate without words, to worried parents, and to his own
intuition while calling on all the skills he acquired in a rigorous medical
education. Always drawn to writing,
Volck takes his writing work (and play) as seriously as his medical practice, and
muses on the role of writing in the medical life as he goes along.

At 16, Alice is diagnosed with leukemia, and is given a dire prognosis. Assuming she has months to live, she undergoes chemotherapy with the support of her lifelong friend, Harvey, whose frank and deepening love she is uncertain about returning. On days when she has enough energy and the nausea abates, she works on a "bucket list" with Harvey's sometimes reluctant help, since the list includes revenge on two classmates who have hurt and humiliated her. When, months into treatment, she goes into unexpected full remission, Alice has to come to terms with the consequences of some of her revenge strategies and reassess the depth of a relationship with Harvey that may last far longer than she thought she had. Given an opportunity to choose life on new terms, she considers those new terms in a more adult way, chastened, focused, and grateful for a chance to make new choices.